Provider First Line Business Practice Location Address:
2048 W 69 ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-571-1118
Provider Business Practice Location Address Fax Number:
310-397-4417
Provider Enumeration Date:
03/19/2009